Sexual Difficulties After Traumatic Brain Injury and Ways to Deal with It

CHAPTER 1 - Traumatic Brain Injury, Disability, and Sexuality

INTRODUCTION

Coping with the impact of traumatic brain injury (TBI) is described in the medical and rehabilitation literature as one of the most difficult tasks that can confront survivors, their families, and professionals (Brooks, 1984; Connell & Connell, 1995; Lezak, 1978; Perlesz, Kinsella, & Crowe, 1999). The National Head Injury Foundation (NHIF) in the U.S. defines Traumatic Brain Injury as "an insult to the brain caused by an external force that may produce diminished or altered states of consciousness which results in impaired cognitive abilities or physical functioning" (NHIF, 1989). Between 55 to 60 % of persons who sustain TBI are estimated as having varying degrees of ongoing physical, cognitive, and behavioral deficits and, therefore, require long-term rehabilitation ( Jacobs, 1988; Kalsbeek, McLaurin, Harris, & Miller, 1980). Physical disabilities associated with TBI can include impairments in vision, hearing, speech, and language, fine and gross motor skills, and balance (Boak & High, 1996). Difficulty in concentrating, different degrees of short-term memory loss, poor retrieval of existing information, problems in processing abstract information, and the impaired planning and carrying out of everyday activities are among the cognitive disabilities produced by TBI (Ponsford, Sloan, & Snow, 1995; Rachmani, 1988; Varney & Menefee, 1993). The emotional and behavioral problems and difficulties in coping that persons with TBI and their families experience are not surprising (Armstrong, 1991; Kaplan, 1993; Vogenthaler, 1987), given the extensive impairment and disability that are often a consequence of TBI (Abrahamson & Abrahamson, 1997; Antonak, Livneh, & Antonak, 1993).

The main causes of TBI are injuries resulting from vehicles; workrelated, sports, and home accidents; violence; and military-related wounds. These injuries can be classified as either closed-head or openhead injuries. Closed-head injuries that result in TBI may be the result of a blow to the head either from a blunt instrument or from the head impacting on a hard surface. Closed-head injuries tend to produce diffuse brain damage with highly variable and unpredictable consequences (Vogenthaler, 1987). The term, "open-head injury" is used to describe TBI caused by local penetration of the skull. Gunshot wounds to the head, where a bullet penetrates the skull and causes damage to the brain, are a common source of open-head injuries. This type of penetrating injury generally results in localized damage and disabilities that are relatively predictable from the location and extent of the damage ( Jennet & Teasdale, 1981). Head injuries can also range from mild to moderate to severe, with the severity and complexity of these injuries’ consequences depending on the severity of the TBI. Although different patterns of neurological damage and resultant cognitive, physical, and behavioral disabilities are associated with closedand open-head injuries, in this book, both kinds of injury are included under the heading of TBI.

Due to advances in medical technology, neurosurgery, and physical treatment in industrialized countries, the number of persons who survive TBI has significantly increased. Whereas two decades ago, only 15 percent of persons sustaining TBI survived, presently 60 percent of these persons survive. According to the 1990 statistics, one million people in the United States annually incur TBI. Recent (1995) statistics show that two million persons per year will incur TBI. Approximately one quarter of these persons will require hospitalization and 50,000 to 70,000 will be left with permanent neurological impairment that will significantly reduce their ability to return to the way of life that they led before the TBI (Zasler, 1995).

Headway, a national head injuries association located in the U.K. estimated that in 1997, more than 120,000 persons in the U.K. experienced the long-term effects of severe head injury. This figure seems to be increasing annually, since survivors tend to be young with normal life expectancy (Headway, 1997). The estimated incidence of TBI in Sweden is approximately five per 1000 inhabitants per year, with traffic accidents as the most common cause (Carlsson Silverpage, 1986). In Israel it was estimated that, in 1990, rehabilitation services were being provided to 2490 survivors of TBI out of a population of 4.2 million (Katz & Florian, 1990).

A relatively high percentage of persons with TBI are under the age of 30 years old, with the age of the majority ranging from 15 years to 24 years (NHIF, 1984). One-third more men than women experience TBI. Demographic descriptions of persons with TBI depict them as having a below-average level of education, premorbid learning problems, and histories of school failure (Tobias, Puri, & Sheridan, 1982). Excessive alcohol intake, drug use, problems with the law, and poor marital relationships have been reported as characterizing these persons prior to the injury. McLaughlin and Schaffer (1985) attribute social dysfunction to persons with head trauma that consists of a history of disruptive or acting out behaviors (60%), drug and alcohol abuse (38%), marital problems (38%), withdrawal from school (18%), and unemployment (16%). Apparently, many persons who sustain TBI have histories of maladaptive problems prior to their incurring the disability. These problems may considerably increase the difficulty of rehabilitating these persons (Sander, Kreutzer, & Fernandez, 1997).

During the last two decades, the number of professionals and rehabilitation programs serving persons with TBI has significantly increased, to help them and their families cope and to facilitate them leading relatively independent lives in the community. This rapid development of community programs was made possible only after TBI was recognized as a specific disability requiring unique intervention techniques developed especially for the disability (McMahon & Fraser, 1988).

Prior to the establishment of these specific programs, rehabilitation services were generally not equipped to deal with persons with TBI because of the lack of knowledge and understanding of the cognitive and psychosocial consequences of TBI. Often persons with TBI were treated according to the dominant symptoms they presented. If the problems were essentially physical, these individuals were treated as if they were physically disabled, with little attention being paid to the associated cognitive impairments. When the persons with TBI presented severe behavioral problems, they were generally perceived as having a psychiatric disorder and, consequently, were hospitalized in institutions for the mentally ill (Katz & Florian, 1990; McMahon & Fraser, 1988).

After TBI was recognized as a separate and unique disability, methods and intervention techniques were developed to deal with the myriad of problems that arise following TBI. In keeping with what is common practice in connection with the rehabilitation of persons with other disabilities, teamwork and interdisciplinary cooperation must be an integral part of the rehabilitation of persons with TBI. The application of a team approach to the rehabilitation of persons with TBI is especially relevant during the first stage of the rehabilitation process, when the ability of the individual to cope with his environment is severely limited (Malik, 1994, 1995).

Despite the advances in the range and quality of intervention techniques available for persons after TBI, only limited attention has been paid to the implications of TBI for these persons’ sexuality. Although many professionals claim to have adopted a holistic approach to this severe disability, the sexual consequences of TBI have often been overlooked or only dealt with superficially (Zasler, 1991). TBI rehabilitation has been gaining legitimate recognition as a rehabilitation specialization. However, for this specialization to help persons with TBI gratify all of their basic human needs, the issue of sexuality post- TBI must also become a major part of the treatment and rehabilitation process, just as it is a major part of normal life. The sexual life domain is especially vulnerable to the negative impact of TBI for the following reasons. As mentioned above, a large percentage of the persons who survive TBI incur this severely disabling condition at that stage of development when the gratification of the need for sexual intimacy is of paramount importance. In addition, the cognitive, emotional, and behavioral consequences of TBI can interfere with sexual functioning and limit the capacity for the initiation and maintenance of intimate relationships. Furthermore, diagnostic labels such as organic brain damage are often associated with social stigma and interpersonal rejection that can interfere significantly with attempts to initiate intimate relationships. Therefore, rehabilitation professionals who counsel persons after TBI should be trained and willing to address issues of sexuality as readily as they address issues relating to employment, mobility, selfcare, cognition, and social skills.

To include the sexual problems of persons with TBI among the problems dealt with by TBI rehabilitation, the definition of the term rehabilitation should be reviewed and broadened. Rehabilitation has been generally thought to consist of the following three related elements: recovery of function to the extent possible, development of compensatory skills in areas where deficits persist, and emotional adjustment to the attained level of functioning (Wright, 1988). Therefore, rehabilitation is a many-sided process that is usually initiated by a multidisciplinary team after the acute phase of a severe and persistent illness or disorder. Not only do the objectives of this process include both the amelioration of and the adjustment to the illness or disorder, but they also aim to achieve optimal quality of life within the limits of continuing physical, mental, and emotional impairment. Since satisfactory interpersonal relationships are a central aspect of quality of life (Dell Orto & Power, 2000), rehabilitation must attend to interpersonal communication training, personal and family adjustment, sexual functioning, and social integration as well as the physical, vocational, and cognitive aspects of the person’s functioning (Greif & Matarazzo, 1984).

As mentioned above, the abnormalization of persons with TBI as a result of disability and social stigma can place a barrier between them and the interpersonal relationships and social integration that are essential for the attainment of quality of life. To deal with this barrier, rehabilitation systems often view the normalization principle as the cornerstone of their efforts at TBI rehabilitation (Dell Orto & Power, 2000). The normalization principle was first formulated in Scandinavia, as part of the public policy to provide persons with disabilities as normal an existence as possible (Nirje, 1969). Many rehabilitation systems throughout the world have since adopted the normalization principle to guide their delivery of rehabilitation services. This principle has been especially influential in promoting comprehensive, community-based rehabilitation services, and in attempts to integrate persons with disabilities into the mainstream of life.

Sexuality and Disability

Human sexuality has both biological and social roots. Social and cultural attitudes endow sexual intimacy with a large part of its meaning and value. Accordingly, the meaning and value of sexuality will vary across historical periods and cultures. In modern society, sexuality not only derives its significance from its reproductive role, but it is also perceived as central to mature adulthood and to personal and interpersonal quality of life (Morgan, 1994). Despite the current view of sexual behavior and experience as an essential ingredient of a fully human life, many rehabilitation professionals still have ambivalent and, sometimes, even negative attitudes toward the sexuality of persons with a disability (Webb, 1994).

Attitudes toward the emotional and sexual needs of persons with disabilities are probably the least discussed of all the problems that these persons confront in their interpersonal interactions (Heslinga, 1994). Rehabilitation literature strongly emphasizes encouraging persons with disabilities to lead as normal a life as possible in such domains as employment, housing, and leisure time activities. However, this literature tends to evade the issue of these persons’ sexual needs, and too many people with disabilities suffer needless anxiety regarding sexuality concerns due to inappropriate attitudes or lack of knowledge on the part of their caregivers and society (Chieger, 1984). Since persons with disabilities have the same range of feelings and needs as persons without disabilities, the relative neglect of these persons’ sexuality has to be remedied so they can live more complete human lives.

Two approaches have been implemented to increase the normalization and community integration of persons with disabilities. One approach consists of managing, structuring, and/or modifying the social environment so that the acceptance of persons with a variety of such disabilities as TBI, psychiatric disorders, and mental retardation is increased. The other approach consists of helping the person with the disability adjust to community living by teaching and providing them with the appropriate skills required for such a task. When these two approaches are applied together, the chances of success are greater (Wehman, 1992).

Crucial for implementation of the above two approaches are the attitudes of the non-disabled toward this process. For example, it is only in the last decade that attitudes toward the sexuality of persons with a disability have significantly changed and become more positive. Prior to this period, and in some cases even today, persons with a disability were considered to be asexual. Morgan (1994) contends that the existence of a sexual side to disability was ignored and went unrecognized by professionals, families, and the public at large, and to be disabled was equated with being sexually dead.

Wright (1983) suggested that the basis for these negative attitudes toward sexuality of persons with disabilities was the "spread effect phenomenon," which refers to the power of a single characteristic to evoke inferences about a person (Dembo, Leviton, & Wright, 1975). All characteristics of the persons are evaluated on the basis of one aspect of their lives. Thus, if you have a disability, this means you cannot work, or you are not capable of love, etc. Being disabled automatically precluded one from having sexual needs or being capable of expressing one’s sexuality. The problem becomes especially harmful when global devaluation takes place so that the person as a person is felt to be less worthy, less valuable, and less desirable (Wright, 1983).

These negative attitudes toward sexuality and disability were expressed in many areas of the lives of persons with disabilities. They range from patronizing responses to subtle avoidance techniques to blatant rejection and, in some cases, sexual, physical, and emotional abuse. While the solution of sterilization is generally no longer an accepted solution for persons with mental retardation, the negative attitudes that motivated this solution often may still exist among caregivers and parents, who now express their negative attitudes in more subtle approaches. If one does not talk about sex and disability, it does not exist. Another example of a negative attitude sugar-coated with good intentions is that people with developmental disabilities ought to be institutionalized for their own protection, where they will be safe from sexual exploitation and temptation. In the past, the need to protect persons with disabilities from abuse and exploitation was the main justification for institutionalizing persons with disabilities, especially those with developmental disabilities. Institutionalization was used as an excuse and justification for the inability of professionals and parents to cope with the difficult issues of integrating these people into society, and relating and coping with their sexuality (Kempton & Kahn 1991). The unrestrained spread of disability is again seen in the attitude that persons who have a disability stand apart from, rather than are part of, the community of others.

These negative attitudes toward the sexuality of persons with a disability pervaded all aspects of sexuality, including relationships and the need to love. Even where the sexual needs of persons with disabilities were recognized, the solutions were perceived to be purely in the area of intercourse, without an understanding of the needs of persons with disabilities for meaningful emotional relationships (Heslinga, 1994). Leading as normal a life as possible must accept the tenet that healthy social and sexual relationships are basic to a person’s adaptation to community life. All professionals would agree today that sexuality is not just about biological functioning and reproductive behavior, but that a person’s sexuality involves her whole personality and is a pervasive influence on every aspect of life (Webb, 1994). One cannot relate to the subject of sexuality and sexual health without appropriately addressing the psychological, social, and environmental issues, as well as the physical or clinical issues (Nosek, 1996).

Sexuality enhances the quality of life, fosters personal growth, and contributes to human fulfillment (Whipple & Gick, 1980). When the term sexuality is viewed holistically, it refers to the totality of a being. It encompasses human qualities, not just the genitals and their functions. It includes all of the qualities—biological, psychological, emotional, social, cultural, and spiritual—that make people who they are. People have the capacity to express their sexuality in any of these areas without necessarily involving the genitalia. As Poorman (1988) states, sexuality is interwoven with every aspect of human existence, and some aspects of sexuality are changing perhaps more rapidly within our lifetime than in any other age. A great deal has been written in the last few years on the need for services to expedite the transition of young people with disabilities from school to adulthood (Wehman, 1992).

Wehman (1992) regards transition from school to adulthood as the life changes and cumulative experiences that occur in the lives of young adults as they move from school environments to more independent living. Examples of transitions include changes in self-awareness, body, sexuality, work, and financial needs. As most teenagers grow into adulthood, they begin to establish their own values. Their confidence levels and how they choose to interact with members of the opposite sex or their own sex, and how successful they are, become very important in the way they see themselves. These issues are important in establishing good self-esteem. People express sexuality, both in data formats and in groups, through their clothes, hairstyles, and recreational activities.

In many countries little attention was given to the psychosexual development of adolescents with disabilities and how to prepare them as responsible sexual adults. The misconceptions and anxieties that often exist in the minds of many young people with disabilities regarding such matters as masturbation and petting are often a result of the negative attitudes of those who have been responsible for their care. Expressions of sexuality by people with disabilities are often perceived with amusement by caregivers in institutions and community housing and there is little wonder that, as a result of the ridicule, many persons with disabilities have strange and distorted ideas and feelings concerning their own sexuality. Sex education is important, and young people with disabilities should be taught and made aware, not only of their responsibility for their actions, but that their needs for personal relationships are entirely normal. They are people first and no different from anyone else in their sexual and emotional needs.

The trend today among professionals and researchers is to focus on developmental issues facing children and adolescents with disabilities, especially how they can develop a sexual identity and express their needs appropriately within the confines of their particular needs and aspirations.

Another issue related to disability and sexuality is the lack of understanding of the differences between persons with various disabilities in their needs and abilities to express their sexuality. People with disabilities are dumped together as a homogeneous group and solutions are sought without any sensitivity to individual differences and needs. In addition to differences in type of disability, they also differ in terms of sex, sexual preference, age, social class, education, race, ethnicity, religion, cultural background, morality, and other variables.

Morgan (1994) maintains that we need to look at the sexuality of persons with disabilities using a dual framework: physical problems and problems of interpersonal relationships. Physical problems relate to the mechanical issues of performing the sex act. Related to this are muscular and neuromuscular deficiencies, hormonal and vascular injuries to the spinal cord that can hamper movement, spasticity, paralysis, and physical impairments found in some chronic illnesses.

Interpersonal relationships relate to the opportunity and ability to form and maintain a meaningful emotional relationship with a significant other. These difficulties are primarily psychological and social in nature. In some cases, they may be related to the emotional inhibitions of the person or the lack of social skills required for meaningful interpersonal interactions, or they may be the result of poor sexual selfimage and negative feelings about oneself. Lack of self-esteem or the belief in oneself that one is lovable is the basis for any sexual relationship. Without this basic belief, it becomes difficult to initiate and nurture a sexual relationship with another. This lack can be defined as an emotional handicap of the person, or as a barrier that prevents the initiation of interpersonal contact and the development of satisfying relationships. The above can be summarized by Ferguson (1994), who points out that a person’s sexuality and his mental health are intimately connected, and disruptions of one may have serious repercussions on the other.

In reviewing the issue of sexuality and disability, one needs to bear in mind that there are situations where people acquire a disability later in life, after they have been in a relationship for a period of time. These are people who have reached a certain status in adulthood, are married, and whose sexual status is or was previously considered normal. They may be married with children and sustain their disability as a result of a work or car accident, violent crime, or the onset of a disabling illness.

Traumatic Brain Damage and Sexuality

The brain is considered the most important organ for establishing and maintaining a sexual relationship and for adequate sexual functioning. Professionals who work with persons after traumatic brain injury are aware of the fact that after the injury, there may be a significant sexual dysfunction (Zasler & Kreutzer, 1991). This awareness has led to an increase in the number of studies and articles on the impact of TBI on sexual functioning (Aloni, 1997).

Surveys of the literature on the long-term effects of TBI on sexual functioning and experience have revealed the development of serious problems and frustrations after the first two years following injury (Blackerby, 1990; Davis & Kolton-Schneider, 1990; Griffith & Lemberg, 1993; Peters, Stambrook, Moore, & Esses, 1990; Zasler, 1995). The surveys also showed that sexual function and behavior did not improve over time, although experience indicated that this was the case in other areas of functioning (Blackerby, 1994).

Neurological disability after TBI may result in sexual dysfunction at both a genital and non-genital level (Zasler & Horn, 1990). To adequately deal with the sexual dysfunction after TBI, it is important to understand the physiology of sexual dysfunction in general and, more specifically, how a head injury can disrupt the physiological determinants of sexuality. As in the case of other disabilities, persons with TBI are often stigmatized, for among other reasons, their problematic sexual behavior and lack of sexual control. These behaviors threaten society and often leave the injured person isolated, with feelings of low self-esteem and frustration. It is proposed that early sexual intervention may minimize some of these asocial behaviors and enable the survivors of TBI to improve their social and sexual adjustment.

As mentioned earlier, problems can be expected in sexual functioning and behavior when the brain sustains an injury. There are several papers published on the effect of brain damage on sexuality, but it is difficult to generalize from these papers. Some are based on case studies (Altman & Pruzanski, 1961), while others are based on groups of patients who sustained injuries to various sites in the brain. The severity of injury of the various subjects was also different, as was the duration of Post Traumatic Amnesia (PTA). Thus, the data are not clearly organized, making it difficult to compare and obtain a clear picture of the effect of localization of injury on sexual functioning. In addition, most research studies are not based on large groups of patients, which also makes generalization and application of localization, severity of injury, or duration of PTA problematic (Bienenfield & Brott, 1989; Blumer, 1970; Burton & Volpe, 1988).

Sexual dysfunction can be classified according to brain localization and function or according to stages of human sexual response. Literature focusing on overall brain function rarely relates to sexual functioning, and most of the data are derived from biological and mammal research (Chusid, 1982; Mesulam, 1988). The literature based on sexual research provides limited information about the role of the brain in human sexual response. Masters and Johnson (1970) did not relate to the issue in their book and only Kaplan (1983) referred to it, but concentrated mainly on the effect and role of the endocrine system, the hypophysis, and pituitary glands in sexual function.

In general, TBI research is moving from focusing on the location of the injury toward evaluating function or dysfunction (Soroker, 1995- 1996). This approach appears to be justified for the field of sexuality because available literature on localization of TBI and sexual function is quite baffling. Various authors attribute a particular sexual dysfunction to damage of different sites of the brain, or different sexual dysfunctions are connected to the same brain localization (Griffith, Cole, & Cole, 1990; Griffith & Lemberg, 1993; Kreutzer & Zasler, 1989). It is also difficult to be precise about the exact location and severity of the injury at that particular site and its effect on sexual function (Mesulam, 1988). One cannot assume that, even when injury to a critical area is proven, the sexual dysfunction is definitely a result of that injury. There are always the emotional and relationship parameters to be considered, rendering the situation more difficult to evaluate.

Upon realization that previous concepts of brain functioning and possible localization of function were inadequate, other methods were explored. Recovery of function, restoration of function, or learning new ways to perform the same function became the focus of this unique field, compelling scientists to study the effect of lesions in the brain on behavior (Soroker, 1995-1996). Rehabilitation of head injury means dealing with a system of immense complexity that creates the necessity of elaborating multiple alternative complex theories. In spite of the intensive and comprehensive study of the impact of TBI, and the rehabilitation techniques that were developed to overcome the problems, the issue of sexuality after TBI has received scant attention, and very few programs for intervention in this sensitive area have been developed.

Ponsford et al. (1995) maintain that TBI has the potential to disrupt many important aspects of sexuality, including social and relationship skills, self-esteem, and behavioral control, as well as libido and the physical capacity to perform sexually. In cases where the person who sustained the injury was an adolescent or young adult, these skills may not have been adequately developed or expressed prior to injury, thus adding to the need to include sexuality into the rehabilitation process (Blackerby, 1994; Ponsford et al., 1995). Sexual dysfunction is generally seen as a disruption to the physical aspects of sex, for example, problems of libido, impotence, premature or retarded ejaculation, vaginismus, or anorganismia, but this view reflects a narrow understanding of normal sexual functioning (Savage, 1987). While these aspects of sexuality are important, sexual dysfunction should be seen in a broader sense, including problems relating to and being emotionally intimate with other people, and practicing appropriate social skills and feelings about oneself as an attractive sexual being.

The process of coping with a physical disability, both for the individual and the family, is based on the assumption that, at the acceptance stage, a balance between the past and the present is achieved. This balance indicates the stabilization of psychodynamic and psychosocial processes and helps in the mobilization of the potential of the individual in order to arrive at a successful rehabilitation. The evidence in the literature relating to the adjustment of persons after TBI indicates that the usual natural adjustment process found in other physical disabilities does not always exist (Florian & Katz, 1991). The deficits in mental and behavioral coping tools have a deleterious effect on the adjustment process. As a direct consequence of these deficits, the family and spouse experience a consistent and sometimes increasing burden over an extended period of time (Abrahamson & Abrahamson, 1997; Perlesz et al., 1999; Rosenbaum & Najenson, 1976). The available information on the cognitive, emotional, and behavioral consequences of TBI, its effect upon sexual function, and the ability to maintain an intimate relationship indicate that it is a very complex and difficult condition. The rehabilitation process of the survivors of TBI is also complicated and long term, which places pressure on both survivors and the people around them. Cognitive and emotional losses, together with personality changes and regression, pose an immense challenge to the intimate relationship and place a great need for change and adaptation that the relationship may not be able to make. Prigatano (1988), in a paper entitled Work, love and play after brain injury, summarizes this in the following quote: "Patients who suffer from higher cerebral disturbance have the curious mixture of perceiving themselves as normal on the one hand and yet at the very same time recognizing an altered capacity in themselves. Frequently they do not know how to identify or deal with this change" (p. 415).

Any program that aims to address sexual rehabilitation would have to address the emotional, cognitive, behavioral, and functional sequelae of TBI in order to achieve its goals. The way to prevent the devastating sexual sequelae of TBI is apparently to break the vicious circle and prevent it from being reinstated. It is important to outfit survivors with the appropriate skills to prevent them from encountering failure at a time when they must learn to cope with the sequelae of TBI. Research on the impact of physical disability on the relationship in the marriage is limited because of the difficulties in obtaining reliable data on pre-disability measures of marital cohesiveness, integration, and adjustment. Nevertheless, it can be assumed that the resources of the couple, such as mutual decision-making, flexibility, and good communication, will contribute to the development of a new balance in the relationship, and adjustment. As has been demonstrated in a number of studies with persons after TBI, however these resources are lacking or limited and, thus, not only do they not contribute to a new balance or adjustment, but their lack will exacerbate feelings of loss and maladjustment.

As the gap in functioning and emotional ability of the couple widens, the feelings of estrangement and marital breakdown will increase. The assumption that, as the husbands become more dependent and regressive in their behavior, the wives will become more depressed, appears to be valid on the basis of the evidence in the literature. Therefore, as mentioned above, an intervention program aimed at dealing with the sexual sequelae after TBI must take into account the wider aspects of interpersonal and emotional relationships if the intervention program is to succeed.

Single survivors will need to start from the beginning, while having almost no previous experience of how to handle a similar situation at a time when his cognitive and emotional strengths and skills are not functioning optimally. Married survivors struggle to maintain their role in the relationship while experiencing multivariate changes in all aspects of their lives. This explains why survivors find themselves almost totally isolated from their significant peers soon after the injury, and the effect this isolation has on their rehabilitation process and sexual opportunities. It explains the struggle that spouses experience in trying to maintain the intimate relationship. It also emphasizes the need for an early intervention program that will fill in the missing part among other rehabilitation programs, and will address sociosexual and intimacy issues. Prigatano (1988) stresses the importance of social contacts for the person with brain injury. It is through social contacts and integration into the community that a person can experience adult love and have partners for play.